Thursday, May 25, 2006

Presumption seems to be Doctors will not do right by patients unless....

Dr. Philip R. Alper's "IM Insights" appearing in "Internal Medicine World Report" monthly continue to be packed with insights born of thoughtful consideration of years of experience. In the April 2006 issue, he discusses " Will the Real Patient Advocate Please Step Forward?"

He recalls from his days of Internal Medicine training in the 60's that the internist was the person who provided "effective and comprehensive patient advocacy that activity being a "cardinal characteristic that set internists apart". Now it seems that numerous voices are telling us that decisions about care that may have previously been a joint effort made the physician and the patient are too important and too likely to be handled badly by the physician to be left in their hands alone.

Now, that advocacy role is being eroded away by several forces, one of which is the multiplicity of entities that all proclaim the need for such advocacy and self proclaim that role for themselves. In the rhetoric of many such advocates the presumption has become "The doctor will not do right by the patient unless other agents intervene "

Who are these advocates and what energizes their activities?

Well, almost everyone, but the most visible and vocal are :the Institute of Medicine,AARP,and the HMOs and insurance carriers and even the American College of Physicians but motivations of various members of this diverse list are not all the same.

Alper asserts that a " kind of blame game " is being played by the carriers.When their,at times, blatant denials of care evoked the ire of the public they backed off a bit shifting to more patient cost-sharing and blaming the high cost of medical careon "poor quality". Patients were not getting good value for their money and of course it is the physician who largely provides that care.It would follow that someone must oversee and manage the physician's care because left to their own devices docs will crank out poor value care.Audits, guidelines,pay for performance (tipping the docs for doing a good job)are,in this view, necessary to protect the patients from the default position of poor quality which physicians typically deliver unless third parties intervene to protect the patient.

Managed Care is a major force in all of this on several levels.On a practical level the time crunch physicians face leaves little time to be an advocate in many situations.More broadly, Managed Care's "quality movement" may well function as a more sophisticated "denial of care"-saving money under the rubric of convincing everyone they are improving care.

The model of independent individual physicians providing care to individual patients is antithetical to those who are strong advocates of a single payer system.A quality gap is a concept they might embrace. A crisis is great opportunity to bring about change.

There are many thoughtful,dedicated physicians who sincerely want to improve care to patients and whose motivations are not those of the insurance carriers which is to save money. There are many aspects of medical care in this country ( and every country) that could and should be improved. Working to do that is not always motivated by the cost containment model but at least some of the rhetoric of "patient advocacy" and "quality" is motivated by exactly that desire. Also, some of that rhetoric is driven by a desire -for whatever reasons- to replace what remnants of fee-for- service medical care by independent physicians still exist with a system less sympathetic to the individual and more attuned to notions of social justice and public health.

How did a profession historically dedicated to the premise of doing the right thing for the patient find itself constantly apologizing for what it does and being blamed largely for being responsible for what is being characterized as crisis in care? Why are we accepting that blame? Why do we not hear of a crisis in legal representation, in the services rendered by architects,contractors, or even car salesman and roofing companies?